230 Exam 2 PrepU Questions
An ER nurse must quickly assess two clients who were in a car accident and determine whose needs take priority. In this situation, critical thinking allows the nurse to: A. consider all factors, interpret the information, and make decisions relevant to each client's care. B. delegate tasks to other ER staff, thereby freeing up more time to care for clients presenting with true emergencies. C. communicate each client's status more efficiently to the attending physician. D. minimize the time spent with each client, so the overall operations of the ER will be more efficient.
A
Cephalosporins are structurally and chemically related to which classes of antibiotics? A. Penicillins B. Fluoroquinolones C. Tetracyclines D. Aminoglycosides
A
The nurse is assigned a client who had an uneventful colon resection 2 days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change? A. unlicensed licensed personnel B. registered nurse C. licensed practical/vocational nurse D. senior student in nursing school who is present for clinical
A
The nurse is caring for a client in the ED following a sexual assault. The client is hysterical and crying. The client states, "I know I'm pregnant now, maybe I have HIV. Why did this happen to me?" Which is the best response by the nurse? A. "Let's talk about this. Do you want me to call a support person?" B. "Do you want the phone number for the National Sexual Assault Hotline?" C. "Would you like us to complete HIV testing?" D. "Do you want to discuss antipregnancy measures?"
A
The nurse is caring for a group of clients. What priority nursing intervention illustrates planned nursing care prioritized according to Maslow's hierarchy of needs? A. Administer pain medication to a client before transportation to physical therapy for crutch-walking exercises. B. Interrupt a family's visit with client with depression to assess blood pressure measurement. C. Discourage a terminally ill client from participating in a plan of care, to minimize fears about death. D. Help a client walk to the shower because the shower area is vacant at this time.
A
The nurse is delegating to the unlicensed assistive personnel (UAP). What is the best instruction by the nurse? A. "Notify me right away if the client's systolic blood pressure is 170 or greater." B. "Let me know if the client's blood pressure becomes elevated." C. "I need to know if the client's blood pressure changes from his normal baseline." D. "If the client's blood pressure falls outside normal limits, come get me."
A
The nurse is reviewing information from a recent disaster management training session. The nurse knows that all of the following activities are part of the preparedness phase of disaster management except for: A. Providing emergency care B. Conducting training and mock disaster response drills C. Designating locations of shelters D. Developing early warning systems and evacuation routes
A
Which client requires priority intervention by a nurse providing care on a medical-surgical unit? A. A client with a blood pressure of 98/40 mm Hg who needs to ambulate to the bathroom B. A postsurgical client who is feeling dizzy and has a heart rate of 45 beats/min C. A newly admitted client who is upset due to a new cancer diagnosis D. An older adult client who is yelling and angry with family members
B
Which medication is the drug of choice for sinus bradycardia? A. Pronestyl B. Atropine C. Cardizem D. Lidocaine
B
The victims of a tornado disaster have been triaged, and a number of victims have been placed in the expectant category based on their injuries. What nursing interventions should be used to care for these clients? Select all that apply. A. Direct to a delayed treatment waiting area. B. Provide comfort. C. Provide emotional support. D. Enlist volunteers to provide first aid. E. Keep airway patent.
B C
A patient was suspected of being in direct contact with anthrax but is exhibiting no signs or symptoms. What type of prophylaxis does the nurse know this patient will have to take? A. Erythromycin for 2 weeks B. Penicillin G IM for 1 dose C. Ciprofloxacin (Cipro) for 60 days D. Rocephin (Ceftriaxone) IV for 7 days
C
G-CSF (filgrastim) is prescribed for a client with bone marrow suppression. What medication administration teaching should the nurse provide to the client? A. Do not eat before arriving to receive the intravenous administration of filgrastim. B. Take this medication by mouth at bedtime each night. C. Assist the client in identifying appropriate subcutaneous injection sites. D. Filgrastim is taken intramuscularly on a weekly basis.
C
What potential adverse reaction is most likely to develop during cefazolin therapy? A. Dry skin and pruritus B. Orthostatic hypotension C. Gastrointestinal upset D. Drowsiness
C
Which solid organ is most frequently injured in a penetrating trauma? A. Brain B. Lung C. Liver D. Pancreas
C
The nurse is instructing on bioterrorism agents. Which of the following does the nurse emphasize as an agent which is transmitted from person to person? A. Varicella B. Anthrax C. Botulism D. Smallpox
D
You are caring for radiation victims. What is the most important factor that you should consider to assess a client's chance of survival in acute radiation syndrome (ARS)? A. Direct physical contact B. Mode of infection C. Concentration of nerve gas D. Dosage of gamma radiation
D
Your hospital has had an influx of clients who are in respiratory distress and require ventilator assistance. What might this indicate? A. A natural disaster B. A neurologic disaster C. A medical disaster D. A bioterrorism attack
D
A client presents to the ED after an unsuccessful suicide attempt. The client is diagnosed with an acetaminophen overdose. The nurse anticipates the administration of which medication? A. N-acetylcysteine B. Naloxone C. Diazepam D. Flumazenil
A
A nurse has been called for duty during a response to a natural disaster. In this context of care, the nurse should expect to do which of the following? A. Practice outside of the nurse's normal area of clinical expertise. B. Perform interventions that are not based on assessment data. C. Prioritize psychosocial needs over physiologic needs. D. Prioritize the interests of older adults over younger clients.
A
The emergency department nurse is caring for clients involved in a chlorine exposure accident at a local chemical plant. The nurse is aware that permanent damage can occur to which body systems? A. Cardiac B. Respiratory C. Renal D. Hepatic
B
The nurse is preparing to admit clients who have been the victim of a blast injury. The nurse should expect to treat a large number of clients who have experienced what type of injury? A. Meningeal tears B. Tympanic membrane rupture C. Chemical burns D. Spinal cord injury
B
A client comes to the emergency department with a suspected airway obstruction. The emergency department team prepares to manage the client as if he has a complete airway obstruction based on which of the following? A. Wheezing between coughs B. Forceful coughing C. High-pitched noise on inhalation D. Refusal to lie flat
C
Homeland Security has alerted the disaster response teams in your region of a potential terrorist attack in the form of a nuclear blast. You are a part of the disaster response system and you know that with a nuclear blast you would need to be prepared for what classification of disaster? A. Chemical B. Biologic C. Manmade D. Radiologic
D
A nurse is providing an educational program for a group of occupational health nurses working in chemical facilities. Which of the following would the nurse include as the priority in the case of a chemical burn? A. Covering the area with a sterile dressing B. Applying antimicrobial ointment C. Rinsing the area with copious amounts of water D. Administering tetanus prophylaxis
C
In a mass casualty event a client has been field triaged and categorized as green. The nurse recognizes that interventions for this client require which of the following priorities? A. Delayed B. Expectant C. Immediate D. Minimal
D
Several patients that have been involved in a bombing are unlikely to survive. What priority are these patients given during triage? A. Priority 3 B. Priority 1 C. Priority 2 D. Priority 4
D
A client is prescribed filgrastim. Which is the nurse's best explanation of how this drug works? A. It stimulates growth and production of WBCs to fight off infection. B. It functions like insulin, lowering the blood sugar. C. It inhibits the growth of bacteria in the body. D. It aids in the development of platelets by the bone marrow.
A
For a patient who is experiencing multiple injuries, which sequence of medical or nursing management would the nurse identify as a priority? A. Control hemorrhage, prevent hypovolemic shock, establish an airway, assess for head injuries. B. Establish an airway, control hemorrhage, prevent hypovolemic shock, assess for head injuries. C. Prevent hypovolemic shock, assess for head injuries, establish an airway, control hemorrhage. D. Assess for head injuries, control hemorrhage, establish an airway, prevent hypovolemic shock.
B
Which aspect of nursing would most likely be defined by legislation at the state level? A. Criteria that clients must meet to qualify for Medicare or Medicaid B. Differences in scope of practice between registered nurses and licensed practical nurses C. Criteria that a nurse must consider when delegating tasks to unlicensed assistive personnel D. The process that nurses must follow when handling and administering medications
B
Three victims of radiation exposure are brought into the Emergency Department. As the nurse caring for these clients, you would expect what substance to be ordered to reduce radiologic organ damage? A. Cyan red B. Potassium iodide C. Russian blue D. Medical iodine
B
A 50-year-old client received atropine preoperatively. The nurse explains the symptom of dry mouth to client as which effect? A. "The medication caused a loss of body fluid." B. "The medication temporarily decreased your salivation." C. "You are probably dehydrated." D. "The medication caused an electrolyte imbalance."
B
A client has been exposed to a vesicant and is undergoing decontamination. Which of the following most likely would be used? A. Chlorhexidine B. Soap and water C. Alcohol D. Sodium hypochlorite
B
A client who has been triaged as delayed would receive which color tag? A. Red B. Black C. Yellow D. Green
C
A client is prescribed the recumbent granulocyte colony-stimulating factor (CSF) filgrastim. The nurse evaluates the effectiveness by monitoring which laboratory value? A. hemoglobulin and hematocrit (H&H) B. Prothrombin time (PT)/partial thromboplastin time (PTT) C. international normalized ratio (INR) D. complete blood count (CBC)/differential
D
A client with a minor burn would be triaged as A. expectant. B. delayed. C. immediate. D. minimal.
D
A hospital's emergency operations plan has been enacted following an industrial accident. While one nurse performs the initial triage, what should other emergency medical services personnel do? A. Classify clients according to acuity. B. Modify the emergency operations plan. C. Provide health promotion education. D. Perform life-saving measures.
D
A nurse needs to administer a cephalosporin to a client. The client informs the nurse that he is allergic to penicillin. Which action by the nurse would be most appropriate? A. Obtain the client's occupational history. B. Obtain specimens for kidney function tests. C. Administer an antipyretic drug. D. Inform the primary healthcare provider.
D
A client is admitted to the ED after a near-drowning accident. The client is diagnosed with saltwater aspiration. The nurse will observe the client for several hours to monitor for symptoms of A. hypothermia. B. pulmonary edema. C. hyponatremia. D. head injury.
B
A 13-year-old is being admitted to the ED after falling from a roof and sustaining blunt abdominal injuries. To assess for internal injury in the client's peritoneum, the nurse should anticipate what diagnostic test? A. Computed tomography (CT) scan B. Barium swallow C. Complete blood count (CBC) D. Radiograph
A
A 21-year-old client admits to recently using diuretics and laxatives to lose weight quickly. The client doesn't want to feel fat in a bathing suit on vacation. The client's sodium level is 150 mEq/L; potassium level is 3.2 mEq/L. The client is 5 feet tall, weighs 100 pounds, and has lost 15 pounds in 3 weeks. Which goal is a priority at this time? A. Stabilize electrolyte levels. B. Develop a contract with the client to stop using laxatives and diuretics. C. Help build self-esteem. D. Assist client to begin gaining weight at the rate of 2 to 3 pounds per week until reaching 112 pounds.
A
A client who has been exposed to anthrax is being treated in the local hospital. The nurse should prioritize what health assessments? A. Assessment for signs of hemorrhage B. Assessment of respiratory status C. Neurologic assessment D. Integumentary assessment
B
A client is admitted to the ED after being involved in a motor vehicle accident. The client has multiple injuries. After establishing an airway and adequate ventilation, the ED team should prioritize what aspect of care? A. Control the client's hemorrhage. B. Splint the client's fractures. C. Assess the client's neurologic status. D. Assess for cognitive effects of the injury.
A
A client is admitted to the emergency department after sustaining a penetrating injury to the abdomen. Which of the following would the nurse identify as a possible cause? A. Stabbing with a knife B. Impact of a steering wheel C. Fall to the ground from a ladder D. Concrete debris from an explosion
A
A client is brought to the ED by two police officers. The client was found unconscious on the sidewalk, the client's face and hands covered in blood. At present, the client is verbally abusive and is fighting the staff in the ED, but appears medically stable. The decision is made to place the client in restraints. What action should the nurse perform when the client is restrained? A. Frequently assess the client's skin integrity. B. Take the opportunity to perform a full physical assessment. C. Avoid interacting with the client until the restraints are removed. D. Inform the client about the likelihood of being charged with assault.
A
A client is scheduled to undergo an exploratory laparoscopy. The registered nurse (RN) asks the licensed practical nurse (LPN) to prepare the client for surgery. The RN must confirm that the LPN has specialized training before delegating which task? A. initiating I.V. therapy, as ordered B. weighing the client C. teaching the client how to collect a urine specimen D. teaching the client coughing and deep breathing exercises
A
A homeless client presents to the ED. Upon assessment, the client is experiencing hypothermia. The nurse will plan to complete which priority intervention during the rewarming process? A. Attach a cardiac monitor B. Insert a Foley urinary catheter C. Administer inotropic drugs D. Assist with endotracheal intubation
A
A nurse is providing discharge instruction to a victim who has been exposed to anthrax but does not have any symptoms. The nurse's teaching includes that prophylactic antibiotics must be taken for: A. 60 days. B. 30 days. C. 14 days. D. 10 days.
A
A patient with frostbite to both lower extremities from exposure to the elements is preparing to have rewarming of the extremities. What intervention should the nurse provide prior to the procedure? A. Administer an analgesic as ordered. B. Massage the extremities. C. Elevate the legs. D. Apply a heat lamp.
A
A soldier is preparing to enter an area in which there is a high risk for chemical exposure to a nerve agent. What should the soldier be given prior to entering this area? A. Mark I automatic injectors that contain 2 mg atropine and 600 mg pralidoxime chloride B. Mark I automatic injectors that contain an antiseizure medication such as carbamazepine C. Mark I automatic injector filled with morphine 10 mg D. Mark I automatic injector filled with cyanide
A
The registered nurse (RN) is responsible for delegating patient care responsibilities to licensed practical nurses (LPNs) as well as ancillary personnel. What would be the most appropriate task to delegate to a nursing assistant? A. Obtaining vital signs for a patient that has been hospitalized for 3 days B. Assessing the degree of lower leg edema in a patient on bed rest C. Recording the size and appearance of a decubitus ulcer D. Measuring the circumference of a patient's calf for edema
A
Which is the most likely weaponized biological agent available? A. Anthrax B. Botulism C. Plague D. Smallpox
A
Which is the nurse's priority question to consider prior to delegating a task to an unlicensed assistive personnel (UAP)? A. Does this task fall within the scope of a UAP? B. What is the client's condition? C. How can I explain the task to the UAP? D. How can I supervise the completion of this task?
A
You are caring for radiation victims. What is the most important factor that you should consider to assess a client's chance of survival in acute radiation syndrome (ARS)? A. Dosage of gamma radiation B. Concentration of nerve gas C. Mode of infection D. Direct physical contact
A
Nursing students are reviewing the categories of intra-abdominal injuries. The students demonstrate understanding of the information when they identify which of the following as examples of penetrating trauma? Select all that apply. A. Gunshot wound B. Knife-stab wound C. Fall from a roof D. Being struck with a baseball bat E. Motor-vehicle crash
A B
A registered nurse is delegating activities to unlicensed assistive personnel (UAP) on a hospital unit. Which activity(ies) could this nurse normally delegate? Select all that apply. A. giving a bed bath to a client B. taking routine vital signs C. planning education for a client with a colostomy D. determining a nursing concern for care planning for a client with breast cancer E. administering medications to a client F. transferring a client to another floor
A B F
A client with suspected inhalation anthrax is admitted to the emergency department. Which action by the nurse takes the highest priority? A. Reassure the client that intubation and mechanical ventilation will be temporary. B. Monitor vital signs and oxygen saturation every 15 to 30 minutes. C. Suction the client as needed to obtain a sputum specimen for culture and sensitivity. D. Assess intake and output and maintain adequate hydration.
B
A client is brought to the emergency department by ambulance. The client is seriously ill and unconscious. No family or friends are present. Which of the following would be most appropriate to do? A. Check the client's record for the name of a family member to call to allow care to be provided. B. Document the client's condition and absence of friends or family for obtaining consent to treatment. C. Ask the ambulance team for information about the client's family to ensure informed consent. D. Explain to the client that care is going to be provided because he is seriously ill.
B
A client who has been diagnosed with cholecystitis is being discharged home from the ED to be scheduled for later surgery. The client received morphine during the present ED admission and is visibly drowsy. When providing health education to the client, what would be the most appropriate nursing action? A. Give written instructions to client. B. Give verbal and written instructions to the client and a family member. C. Telephone the client the next day with verbal instructions. D. Give verbal instructions to one of the client's family members.
B
A 23-year-old woman is brought to the ED complaining of stomach cramps, nausea, vomiting, and diarrhea. The care team suspects food poisoning. What is the key to treatment in food poisoning? A. Assessing immunization status B. Determining the source and type of food poisoning C. Determining if anyone else in the family is ill D. Administering IV antibiotics
B
A charge nurse has assigned a new nurse a task that the nurse has not been trained to perform. Which is the most appropriate action for the nurse to take? A. Delegate the intervention to an unlicensed assistive personnel. B. Consult with the charge nurse before performing the procedure. C. Review the procedure in the procedure manual before performing the intervention. D. Perform the procedure and inform the charge nurse of the results.
B
A client has a gaping wound on his forearm that is bleeding profusely. Applying pressure to which pressure point would be most helpful? A. Femoral B. Brachial C. Radial D. Subclavian
B
A nurse is preparing a patient for a barium enema. Which one of the following is a nurse's responsibility for diagnostic procedures and tests? A. writing the order for the procedure or test B. providing emotional and physical preparation C. ensuring results of diagnostic tests are recorded D. delegating care during a procedure to others
B
A nurse is working with a group of disaster victims to reduce the psychological effects of the trauma. Which of the following would be least helpful? A. Actively listening to the victims' concerns. B. Encouraging the victims to watch television replays of the event. C. Encouraging victims to return to normal activities as they feel ready. D. Referring victims to appropriate social service agencies.
B
A nurse volunteers to help decontaminate a victim. Which is the first action that the nurse should take? A. Applying chemical decontamination foam to the area B. Removing the victim's clothing and jewelry C. Washing victim with soap and water, then rinsing D. Dressing the victim in personal protective equipment
B
A triage nurse is working in the emergency department of a busy hospital. Four clients have recently been admitted. Patient A has an arrhythmia diagnosed as atrial fibrillation; Patient B is in chronic congestive heart failure; Patient C is assessed and found to have a probable pulmonary embolism; Patient D complains of chest pain relieved by nitroglycerin and rest. Which client would be the nurse's highest priority? A. Patient D B. Patient C C. Patient B D. Patient A
B
Adherence to defined principles is recommended when delegating care tasks to assistive personnel. According to these principles, who is responsible and accountable for nursing practice? A. The nurse manager B. The registered nurse C. The unit's medical director D. The American/Canadian Nurses Association
B
An emergency department (ED) nurse is triaging clients according to a triage severity rating. When assigning clients to a triage level, the nurse will consider the clients' acuity as well as what other variable? A. Whether other hospitals are on diversionary status and ability to manage the client B. The resources that the client is likely to currently require C. The client's or insurer's ability to cover the cost of care D. The likelihood of a repeat visit to the ED in the next seven days
B
Medical and nursing interventions for patients who present with multiple injuries follow a sequence of treatment priorities. Which of the following is the first priority of care? A. Control hemorrhage. B. Establish an airway. C. Prevent hypovolemic shock. D. Assess for head and neck injuries.
B
The nurse is triaging people that have been involved in a bus accident. A triaged patient with psychological disturbances would be tagged with which color? A. Red B. Green C. Yellow D. Black
B
The nurse receives morning lab work after shift hand-off. Based on the analysis of lab values, which client would the nurse assess first? A. a client diagnosed with type 1 diabetes and a blood sugar level of 175 mg/dL (9.71 mmol/L) before breakfast B. a client diagnosed with renal disease and a serum potassium level of 6.1 mEq/dL (6.1 mmol/L) who has limited output C. a client with diagnosed hypoparathyroidism with a serum calcium level of 8.2 mEq/dL (2.05 mmol/L) who is having cramping in the legs D. a client diagnosed with diabetes insipidus with a urine specific gravity of 1.002 who is asking for morning coffee
B
The registered nurse (RN) wants to delegate measuring a client's urinary output to an unlicensed assistive personnel (UAP). Which factors should the nurse consider before delegating the task? A. The complexity of the activity, age of the UAP, and predictability of the outcome B. The stability of the client's condition, potential for harm, and complexity of the activity C. Predictability of the UAP, the amount of time required for the task, and RN's skill level D. The context of the other client needs, the desired outcome, and autonomy of the client
B
A client with multiple injuries is brought to the emergency department by ambulance. The client has had his airway stabilized and is breathing on their own. The nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding? A. Absence of bruising at contusion sites B. Increased BP with narrowed pulse pressure C. Rapid pulse and decreased capillary refill D. Sudden diaphoresis
C
A float nurse is assigned to a surgical unit. The nurse is receiving two clients from the post-anesthesia care unit (PACU) at the same time. When delegating tasks to other unit personnel who are not known to the nurse, which question would be most important to ask? A. What is your highest educational level? B. Which task would you prefer to perform? C. Are you comfortable performing the tasks assigned? D. How long have you worked on this floor?
C
A nuclear accident (intentional or unintentional) can cause significant harm to those living nearby or at a distance. Harmful levels of invisible gamma radiation penetrate the body, not only causing devastating injuries but possibly contaminating others. What type of transmission precaution prevents such person-to-person contamination? A. droplet B. standard C. contact D. airborne
C
A nuclear reactor overheated, releasing radiation throughout the plant. A worker close to reactor received at least 800 rads and has had an onset of vomiting, bloody diarrhea, and, when brought to the hospital, was in shock. What is this patient's predicted survival? A. Likely B. Possible C. Improbable D. Probable
C
A nurse evaluates clients prior to discharge from a hospital setting. Which action is the most important act of evaluation performed by the nurse? A. The nurse evaluates the competence of nurse practitioners. B. The nurse evaluates the types of health care services available to the client. C. The nurse evaluates the client's goal/outcome achievement. D. The nurse evaluates the plan of care.
C
A nurse is receiving report from the night shift about four clients. Which client would the nurse see first? A. A 29-year-old woman with a history of drug abuse and a heart rate of 124 beats/min B. A 57-year-old woman who had surgery yesterday for a small bowel obstruction with possible wound dehiscence C. A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min D. A 23-year-old woman who had a mountain biking accident in which she suffered a neck fracture and now has numbness and tingling in her right arm
C
A nurse is triaging clients after a chemical leak at a nearby fertilizer factory. What is the guiding principle of this activity? A. Allocating resources on a first-come, first-served basis B. Allocating resources to the youngest and most critical C. Doing the greatest good for the greatest number of people D. Assigning a high priority to the most critical injuries
C
A nurse receives the assignment of clients for the shift. Following the report, which client should the nurse see first? A. a client with a sodium level of 135 mEq/L and a potassium level of 3.7 mEq/L 7 days after a kidney transplant B. a client experiencing mild pain from urolithiasis C. a client 3 days after a kidney transplant with a sodium level of 110 mEq/L and a potassium level of 2.0 mEq/L after dialysis D. a client with pinkish mucus discharge in the appliance bag 2 days after an ileal conduit
C
A nurse working in an emergency department is responsible for determining the severity of the patients' problems and how fast each needs to be seen. The nurse is implementing which of the following? A. Discharge planning B. Crisis intervention C. Triage D. Referral
C
A nursing instructor is describing the role of a nurse during a disaster. Which of the following would best reflect the nurse's role? A. Client care within the area of expertise B. Directly specified by the physician in charge C. Variable depending on the needs of the situation D. Provision of comprehensive client-specific care
C
A patient was brought into the ED after sustaining injuries due to an explosion while welding. The patient is breathing but has an oxygen saturation of 90%, a respiratory rate of 32, and is coughing. What is the priority action by the nurse? A. Administer oxygen at 2 L/min via nasal cannula. B. Start an IV of normal saline solution at 125 mL/h. C. Administer oxygen with a nonrebreather mask. D. Obtain a chest x-ray.
C
A woman is brought to the emergency department by her husband, who reports that his wife "accidentally fell down a flight of steps and broke her arm." The patient is very quiet and withdrawn. During the examination, inspection reveals numerous bruises at different stages of healing over the patient's legs, arms, and abdomen. The nurse suspects abuse. Which of the following questions would be most appropriate for the nurse to use to gather additional information? A. "You have bruises all over your body. Your husband is beating you, isn't he?" B. "Now tell me, did you really fall down the stairs like your husband said?" C. "I've noticed several bruises here and there. Can you tell me what happened?" D. "Your husband has no right to do this to you. Do you want me to call the police?"
C
During a mass disaster, the nurse is caring for a victim whose status has been categorized as yellow during triage. How should the nurse best allocate time and resources to this client's care? A. Place a low priority on the client's care because the client will likely recover independently B. Forego immediate care because the client is unlikely to survive C. Delay the client's treatment for a few hours if other clients need immediate care D. Provide high-priority, immediate care to save the client's life
C
Prioritizing client care is an ongoing process within the art of nursing. Abraham Maslow proposed five levels of need and grouped them according to significance. Which client need is of primary importance? A. being able to keep up with current events while ill B. being safe from falling C. breathing easily D. liking one's roommate
C
The nurse is assigned a client with end-stage ovarian cancer with recurrent ascites, and the client is to undergo paracentesis. Which activity is best to delegate to an experienced licensed practical nurse (LPN/VN)? A. providing discharge instructions after the paracentesis B. completing the client admission C. vital signs every 15 minutes after the paracentesis D. obtaining a paracentesis tray from central supply
C
The nurse is caring for an intensive care unit client who has died with family members at the bedside. The death was sudden and unexpected resulting from a car accident that took place three days ago. The family is upset and the client's partner, crying loudly, yells, "How did this happen? We were just about to celebrate his birthday. He can't be gone!" The family member continues to cry inconsolably. How should the nurse respond? A. "It is important to face the reality that he is gone." B. " I will get you some medication that will help you feel more calm." C. "We did everything we could possibly do to try to save his life." D. "He has passed on to a better place now."
C
The nurse is caring for three clients who have been diagnosed with anthrax. They were exposed after boarding a flight where a white powdery substance was found in one of the restrooms. The nurse knows that these clients would be classed as being victims of which of the following? A. A chemical disaster B. A radiologic disaster C. A biologic disaster D. A natural disaster
C
The nurse is triaging victims after an explosion at an oil refinery. One victim reports tinnitus, dizziness, and otorrhea. For what probable condition should the nurse prepare care? A. Abdominal injury B. Head injury C. Tympanic rupture D. Blast lung
C
The nurse received a patient from a motor vehicle accident who is hemorrhaging from a femoral wound. What is the initial nursing action for the control of the hemorrhage? A. Immobilize the area to control blood loss. B. Elevate the injured part. C. Apply firm pressure over the involved area or artery. D. Apply a tourniquet.
C
The registered nurse on a busy telemetry floor is delegating tasks to an unlicensed assistive person (UAP). Which task is appropriate for the UAP to complete? A. Assessing a client's wound B. Taking an order over the telephone from a health care provider C. Bathing a combative client D. Inserting an indwelling urinary catheter
C
When providing care to a client who has experienced multiple trauma, which of the following would be most important for the nurse to keep in mind? A. Injuries have occurred to at least three distinct organ systems. B. Most multiple trauma victims exhibit evidence of the trauma. C. The client is assumed to have a spinal cord injury until proven otherwise. D. The most lethal injuries are often the most readily apparent.
C
Which client should the nurse prioritize as needing emergent treatment, assuming no other injuries are present except the ones outlined? A. A client with a possible fractured tibia with adequate pedal pulses B. A client with a sore neck who was immobilized in the field on a backboard with a cervical collar C. A client with a blunt chest trauma with some difficulty breathing D. A client with an acute onset of confusion
C
Which guideline is appropriate for a nurse to implement while helping family members cope with the sudden death of a loved one? A. Inform the family that the client has passed on. B. Obtain orders for sedation for family members. C. Show acceptance of the body by touching it, giving the family permission to touch. D. Provide details of the factors attendant to the sudden death.
C
You are an Emergency Department nurse who has to care for three victims of anthrax. The first victim inhaled the toxin, the second victim ingested it, and the third victim suffered a skin infection. Which client should be cared for first? A. Any convenient order B. The one who ingested the toxin C. The one who inhaled the toxin D. The one with the skin infection
C
A client asks the nurse how a broad-spectrum antibiotic works. The best response would be that they are active against: A. only Gram-positive infections. B. only gram-negative infections. C. a wide variety of viruses. D. a wide variety of Gram-positive and Gram-negative bacteria.
D
A client is being treated following a terrorist attack. The client is experiencing visual disturbances, nausea, vomiting, and behavioral changes. The nurse suspects this client has been exposed to what chemical agent? A. Vesicant B. Blood agent C. Pulmonary agent D. Nerve agent
D
A homeless person is admitted the ED during a blizzard, and is unable to feel the feet and lower legs. Core temperature is noted at 33.2°C (91.8ºF). The client is intoxicated with alcohol at the time of admission and is visibly malnourished. What is the triage nurse's priority in the care of this client? A. Addressing the client's alcohol intoxication B. Addressing the client's malnutrition C. Addressing the client's frostbite in his lower extremities D. Addressing the client's hypothermia
D
A nurse is delegating the collection of urinary output to an assistant. What should the nurse tell the assistant to do while measuring the urine? A. Compare the amount of output with intake. B. Tell the patient to wash the urethra before voiding. C. Use a clean measuring cup for each voiding. D. Wear gloves when handling a patient's urine.
D
A nurse is providing care to several assigned clients and decides to delegate the task of morning vital signs to unlicensed assistive personnel. The nurse would assume responsibility and refrain from delegating this task for which client? A. A middle-aged client who had abdominal surgery 3 days ago and is ambulating in the hall B. An adult client who is being treated for kidney stones C. An older adult with pneumonia who is being discharged to the son's home tomorrow D. A client with a high fever receiving intravenous fluids, antibiotics, and oxygen
D
A nurse is providing wound care to a patient who arrived at the emergency department after being hit by flying glass from a broken window. The nurse asks the patient about his last tetanus shot. Which statement would indicate to the nurse that the patient needs a tetanus booster? A. "I just had a tetanus shot last year when I cut my foot on a piece of metal." B. "My last tetanus shot was 2 1/2 years ago during a check-up." C. "I had one last month after I was injured at work." D. "It must be at least 6 or 7 years since I had one."
D
A nurse who is working as part of a disaster response team is performing triage at a mass casualty incident. One of the victims has a sucking chest wound. The nurse would triage this client using which color-coded tag? A. Yellow B. Black C. Green D. Red
D
A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following actions would be the first priority? A. Positioning to prevent complications B. Determination of the cause C. Assessment of pupillary light reflexes D. Maintenance of a patent airway
D
A patient has experienced blunt abdominal trauma from a motor vehicle crash. The nurse assesses the patient, knowing that which organ is the most frequently injured solid abdominal organ? A. Duodenum B. Large bowel C. Pancreas D. Liver
D
An adolescent is brought to the ED after a vehicular accident and is pronounced dead on arrival (DOA). When the parents arrive at the hospital, what is the priority action by the nurse? A. Ask the emergency physician to medicate the parents so that they can handle their child's unexpected death quietly and without hysteria. B. Ask them to sit in the waiting room until she can spend time alone with them. C. Speak to one parent at a time in a private setting so that each can ventilate feelings of loss without upsetting the other. D. Speak to both parents together and encourage them to support each other and express their emotions freely.
D
An industrial site has experienced a radiation leak and workers who have been potentially affected are en route to the hospital. To minimize the risks of contaminating the hospital, managers should perform what action? A. Place all potential victims in reverse isolation. B. Place hospital staff on abbreviated shifts of no more than 4 hours. C. Have hospital staff put on personal protective equipment. D. Establish a triage outside the hospital.
D
Four clients injured in an automobile accident enter the emergency department at the same time. The triage nurse evaluates them immediately. The nurse should assign the highest priority to the client with the: A. second-trimester pregnancy in premature labor. B. severe head injury and no blood pressure. C. lumbar spinal cord injury and lower extremity paralysis. D. maxillofacial injury and gurgling respirations.
D
The LPN is collaborating with the RN in developing a plan of care for a new client. Which description of nursing roles best describes the LPN's contribution to the plan? A. Establishment of priorities during the planning phase B. Identification of problems and risks that require nursing management during the nursing diagnosis phase C. Providing referrals and delegating and managing client care during the implementation phase D. Data gathering, identification of client strengths, and assurance of client safety during the assessment phase
D
The NATO triage system uses color-coded tagging to identify severity of injuries. A patient with survivable but life-threatening injuries (i.e., incomplete amputation) would be tagged with which color? A. Yellow B. Green C. Black D. Red
D
The charge nurse is unable to replace a registered nurse for a shift on an acute medical unit. The staffing department states they are able to send an additional unlicensed assistive personnel (UAP) to assist. What priority action would the charge nurse take in this situation? A. Refuse to create the client assignment and tell management that a nurse must be found. B. Notify the local nursing regulating body about the unsafe working conditions at the facility. C. Call charge nurses on other units to request a registered nurse come assist on the unit. D. Create the client assignment by considering available staff's skill level and client needs.
D
The most important responsibility of the nurse is to prioritize and ensure that routine nursing measures on non-critical clients are assigned. The nurse is performing which functions? A. clinical coordination B. advocacy C. networking D. delegation
D
The nurse is attempting to ambulate a client who underwent shoulder surgery earlier in the day, but the client is refusing to do so. What action by the nurse is most appropriate? A. Delegate the task to the unlicensed assistive personnel. B. Use multiple staff members to remove the client from the bed. C. Document the client's refusal. D. Reinforce the importance of early mobility in preventing complications.
D
The nurse is instructing volunteers at an emergency bioterrorism drill about the management and medications required to combat various viruses, bacteria, and toxins. The nurse knows that the volunteers understand the instruction when they state that managing clients who exhibit symptoms of the variola virus (smallpox) includes A. radiation. B. acyclovir. C. decontamination. D. isolation.
D
The nurse is triaging patients from a 10-car pile-up on the interstate and assesses a patient with a sucking chest wound. What category should this patient be placed in? A. Priority 3 B. Priority 2 C. Priority 4 D. Priority 1
D
The nurse is working with a licensed practical nurse (LPN) and delegating the taking of vital signs for a preoperative client. Upon review of the chart as the client is leaving for the operating room, the nurse notes that the temperature is 101.1°F (38.4°C) and the pulse is 110 bpm. What are the nurse's initial actions? A. Sign off the chart but flag that vital signs are abnormal; allow the client to go to the operating room. B. Have the LPN take the vital signs again, phone the operating room, and cancel the surgery. C. Take the vital signs, and in the future do not delegate this preoperative responsibility. D. Notify the surgeon and await the surgeon's decision; reinforce with the LPN the importance of reporting abnormal preoperative vital signs.
D
The nurse on the adolescent unit delegates a task to the nursing assistant. After delegating the task, the nurse should: A. keep asking the nursing assistant if the task has been completed. B. document in the chart that the task has been completed. C. assume the nursing assistant has completed the task to the nurse's satisfaction. D. allow adequate time for the nursing assistant to complete the task, then follow-up with the nursing assistant.
D
When discussing cephalosporins with the nursing class, the pharmacology instructor explains that this classification of drug is primarily excreted through which organ? A. Skin B. Lung C. Liver D. Kidney
D